Preferred Worker Program - Quarterly Claim Cost Reimbursement Request Worksheet - Oregon 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Insurer' information at the top of the form. This includes the name of the insurance company handling your claim.
3. Fill in the 'Quarter' and 'Year' fields to specify the time period for which you are requesting reimbursement.
4. Indicate the 'Claim status' by selecting either 'Preferred Worker number' or marking if it is a nondisabling or disabling claim.
5. Provide your 'Insurer claim number' and list the names of all claimants in alphabetical order, formatted as last name, first name.
6. Document important dates such as the 'Date of new injury' and 'Date of hire for this job'.
7. In the section for costs, detail each type of disability benefits (TTD, PPD) and medical benefits incurred during this quarter.
8. Finally, calculate and transfer total costs to Page 1 as instructed, ensuring all figures are accurate before submission.

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